Acute Decompensated Heart Harborview Medical Center

Compiled by EFGibbons MD University of Washington Harborview Medical Center Cardiology

Failure
Diagnosis Prognosis
Treatment Hypertensive ADHF
Rapid Assessment ADHF: Predictors of Mortality Adapted from J. Young MD and J. D. Kirk, MD.; HFSA

Hypertensive ADHF
If continued
improvement
Adjust
ACE/ARB/BB
Spironolactone
(Mortality % of 2000 ADHF admissions) SBP >140 mm Hg Consider
Consider BiPAP for Resp Failure Good response: adequate
Admit to observation lete discharge
urine output, SBP >90 mm Comp
unit or in-hospital
Rx Group Typical Signs and Symptoms Typical Hemodynamics Hg, SBP <210 mm Hg,
telemetry floor CHF
Less than BUN 43 mg/dL Greater than Immediate topical troponin negative
Bun
dle
or sublingual NTG
N= 2000
Dyspnea SBP >140 mm Hg 
HypertensiveADHF n=1520 8.91% n= 436 Start IV diuretic If good If
Pulmonary edema Increased heart rate response worsens If unchanged or Consider
Rales Moderate to severe PCWP 2.68% 8.98% not improved
additional
(vascular failure) Minimal weight gain elevation May add IV vasodilator therapy
Signs of end-organ hypoperfusion Normal or mildly decreased CI (NTG, Nesiritide,
Common; ~50% CNS symptoms Killip class II-IV SBP 115 mm Hg SBP 115 mm Hg Nipride)
Rapid onset Preserved LV function < n= 1508 > < n= 433 >
Re-assess severity
n= 248 n= 1260 n= 124 n= 309
Dyspnea SBP 90-140 mm Hg
NormotensiveADHF Pulmonary edema (+/-) Normal or mildly  heart rate 5.49% 2.14% 15.28% 6.41% Poor response: inadequate urine output, Admit to ICU
SBP <90 mm Hg, SBP >210 mm Hg,
Rales (+/-) Mild PCWP elevation troponin elevated, tachycardia, high
(cardiac failure) Peripheral edema Normal or mildly decreased CI
Gradual symptom onset (days/weeks) Killip class II-III
Cr 2.75 mg/dL respiratory rate

< n= 124 >

Common; ~47% Weight gain LV dysfunction
Normotensive ADHF
n= 86 n= 38 Adapted from J Young MD and J. D. Kirk, MD.
Poor response: inadequate
Dyspnea SBP <90 mm Hg 12.42% 21.94% Add IV vasodilator
HypotensiveADHF Pulmonary edema Increased heart rate Adapted from: CART, classification and regression tree;
Normotensive ADHF urine output, poor renal
function, diuretic (NTG, NES, Nipride)
Fonarow GC et al. JAMA. 2005;293:572-580. SBP 90-140 mm Hg Consider
Narrow pulse pressure Moderate to severe decrease in resistance, elevated SBP,
(includes patients with additional
(low cardiac output/ Signs of end-organ hypoperfusion CI troponin elevation
APE)
cardiogenic shock) Altered mental status Mild to moderate PCWP Prognosis is worsened still with: If not
therapy
Cool extremities elevation
Uncommon; ~3% Decreased urine output Killip class III-IV
History of multiple admissions for ADHF improved
If
If good If
Diuretic resistance Severe LV dysfunction Hypoxia, tachycardia; endotracheal intubation IV diuretic response worsens plete
worsens
Com
Adapted from: Adams KF Jr et al. Am Heart J. 2005;149:209-216. DiDomenico RJ et al. Ann Pharmacother. 2004;38:649-660. Gheorghiade M et al.
ECG with LVH, ischemia or MI Good response:
Admit to ICU
CHF
Am J Cardiol. 2005;96(suppl 6A):11G-17G. Nieminen MS et al. Eur Heart J. 2005;26:384-416.
SBP, systolic blood pressure; PCWP, pulmonary capillary wedge pressure; CI, cardiac index; LV, left ventricle; CNS, central nervous system. Elevated Troponin, even without MI; BNP > 500 adequate urine Admit to ED
Bun
dle
output, renal observation unit or
Persistent symptoms or signs of fluid overload at discharge Estimate severity function, normal SBP, in-hospital telemetry 
Left ventricular systolic dysfunction troponin negative floor Adjust
Clinical Diuretic resistance If continued
ACE/ARB/BB
Spirololactone
 “Cardiorenal Syndrome” : improvement
Assess for CRT
History: Personal or Fam Hx of HF, MI, arrhythmia, heart surgery, o Rising creatinine with edema SBP low Follow pathway for
Consider
(<90 mm Hg) discharge
murmur, CVA ,PVD o Hyponatremia treating hypotensive
ADHF
PE: Blood Pressure both arms, Heart Rate, Temperature , o < 50 cc/hr urine output
Diaphoresis, Hypotensive ADHF Right Heart Cath for
Skin turgor, temperature, cyanosis
Pulmonary congestion, Hepatomegaly
Cardiology Consultation in Heart Failure (HF): Adapted from J Young and J. D. Kirk, MD Hemodynamics
Addition of IV
Hypotensive ADHF vasodilator*
Low cardiac output/cardiogenic shock (NTG, Nesiritide) to
JVP, Hepatojugular reflux, S3, Murmurs
Carotid and peripheral pulses/bruits
•AMI with Heart Failure •New LVEF < 40% Evidence of decreased perfusion Wean inotrope
Altered mental status
Peripheral and presacral edema •Pulmonary Edema/Respiratory Failure •HF with new LBBB Poor Urine Output If good response after
SBP <90 mm Hg inotrope discontinuation
•HF with Chest pain •Isolated Right Heart Failure
Lab: CBC, plts, INR, BMR, CPKMB, troponin, liver panel, Cr Clearance •HF with Syncope •HF with Diuretic resistance
Rule out volume depletion: volume
challenge
If continued low Consider transfer to Complete
Rule in severe LV Systolic Dysfx
BNP if HF equivocal, ABG in severe HF and in diabetics •HF with Sustained Arrhythmia •HF with readmission < 3 mos (Stat ECHO) output in-hospital telemetry
floor CHF
Typically Initiate IV inotrope
•HF with Hypotension •HF with Non-compliance Bundle

BNP: BNP < 100 (HF 2%); BNP 100-500 (HF 75%); BNP > 500 (HF
(milrinone, dobutamine, dopamine)
OR Vasodilator (NTG, Nesiritide) If no
improvement
If continued
improvement 
IV Diuretic
95%) Adjust
Caveats: BNP falsely low when BMI > 30, in acute valvular Dz and
constriction
Goals of Treatment: CHF Bundle Completion AND: Admit ICU
IABP
VAD
ACE/ARB/BB
Spironolactone
adapted from European Heart Journal (2005) 26, 384–416 Transplant Assess for CRT
BNP also elevated in AMI, chronic LVSD, PE, CRI, cor pulmonale and Assess for response to Hospice Ready for
therapy
elderly CHF Bundle: Clinical Hemodynamic discharge

BNP diurnal variation makes daily assessment of BNP unwarranted for Tobacco cessation  Symptoms (SOB/ PCWP to <18 mmHg
mgmt advice fatigue)  Cardiac output and/or Diuretic Resistance Maintain IV Furosemide
Measure LVEF  Clinical signs S.V. to target symptom relief,
Yes baseline weight or
ACE/ARB for LVEF<  Body weight Outcome Yes Give total
rise in creat > 40%
ECG:
daily dose
Assess for rhythm disorder, ischemia, MI (old or new), LVH, 40%  Diuresis  Length of stay in the CCU As IV dose
Discharge  Oxygenation  Duration of Response of
RVH, LBBB, low voltage, atrial enlargement Instructions: Is Pt taking 200-250 cc/hr Maintain KCl
Laboratory hospitalization Loop diuretic Over 3-4 hrs, Add MgO for K < 3.5
Meds Electrolyte normalization Time to hospital at home? then 100-150 cc/hr Minimize thiazide dose
Activity  BUN and/or creatinine readmission Give 40 mg
CXR: Assess for cardiac size, pulmonary congestion, infiltrate,
Dietary
Weights
 Bilirubin/AST
 Plasma BNP
 Quality of Life and
Stamina No
Furosemide IV
Convert to IV infusion (5 – 20 mg/hr)
Or
Add thiazide 30’ before AM furosemide
effusions, vascular calcifications, aortic or pulmonary artery Appointment Blood glucose  Mortality
No Or
Trial of IV Bumetanide or Torsemide
enlargement. LV size and pulmonary congestion may be called absent What to do if normalization Tolerability Or
Hemofiltration (CVVH) if diuretics fail
in 20-30% of CXR Symptoms Low rate of noncompliance
worsen Low incidence of side
effects
 Chronic Heart Failure Harborview Medical Center
Compiled by EFGibbons MD University of Washington Harborview Medical Center Cardiology

Diagnosis Evaluation
Treatment
Definition: Initial (and follow up chronic HF): Patient Education
Assess clinical severity of HF by history and physical
“HF is a syndrome caused by cardiac dysfunction, generally resulting from myocardial examination Elements of Education Skill Building and Critical Target Behaviors
muscle dysfunction or loss and characterized by left ventricular dilation or hypertrophy. Consider angina equivalents Definition of HF (linking disease, Discuss basic HF information, cause of patient’s HF, and
Whether the dysfunction is primarily systolic or diastolic or mixed, it leads to Symptoms of cerebral hypo-perfusion/ pre-syncope symptoms and treatment) and how symptoms are related
neurohormonal and circulatory abnormalities, usually resulting in characteristic symptoms Symptoms of thrombo-embolic events
Symptoms of sleep-disordered breathing
cause of patient’s HF
such as fluid retention, shortness of breath, and fatigue, especially on exertion. In the Recognition of escalating symptoms Monitor for specific signs and symptoms ( e.g., increasing
Assign a symptom grade (New York Heart Association
absence of appropriate therapeutic intervention, HF is usually progressive at the levels of
(NYHA) Class): and selection of appropriate fatigue doing usual activities, increasing shortness of breath
cardiac function and clinical symptoms. The severity of clinical symptoms may vary
Class I: No limitation of physical activity. Ordinary physical activitydoes not cause undue fatigue, treatment in response to particular with activity, shortness of breath at rest, need to sleep with
substantially during the course of the disease process and may not correlate with changes palpitation, or dyspnea.
symptoms increasing number of pillows, waking at night with shortness
in underlying cardiac function. Although HF is progressive and often fatal, patients can be Class II: results
Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity
in fatigue, palpitations, or dyspnea. of breath, edema).
stabilized and myocardial dysfunction and remodeling may improve, either spontaneously Class III IIIA: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity
or as aconsequenceof therapy.
causes fatigue, palpitation, or dyspnea. Perform and document daily weights
IIIB: Marked limitation of physical activity. Comfortable at rest, but minimal exertion causes
In physiologic terms, HF is asyndrome characterized by elevated cardiac filling pressureor Class IV Unablefatigue, palpitation, or dyspnea. Develop action plan for when and how to notify the provider
inadequate peripheral oxygen delivery, at rest or during stress, caused by cardiac
to carry on any physical activity without discomfort. Symptoms of cardiac
insufficiency present at rest. If any physical activity is undertaken, discomfort is increased. Institute flexible diuretic program, if appropriate
dysfunction.” Indication and use of each Reiterate medication dosing schedule, basic reason for
HFSA Heart Failure Practice Guideline J Card Failure 2006;12: e10 medication specific medications, and what to do if a dose is missed
Importance of risk factor Smoking cessation
Determine the etiology of HF modification State blood pressure goal and know own blood pressure
Evaluate for chronic coronary disease / from recent measurement
Classification myocardial ischemia
Specific diet recommendations:
Maintain normal HbA1c, if diabetic
Reiterate recommended sodium intake
Evaluate the risk of life-threatening arrhythmias
Identify factors promoting HF exacerbation individualized low sodium diet; Demonstrate how to read a food label to check sodium
Identify co-morbidities which influence or modify recommendation for alcohol intake amount per serving and sort foods into high- and low-
therapy sodium groups.
Identify barriers to adherence or compliance Reiterate limits for alcohol consumption and need for
abstinence if history of alcohol abuse
Standard Lab Tests (Level of evidence= B) Specific activity/exercise Reiterate goals for exercise and plans for achieving
Blood: CBC, CMR, Lipid profile, U/A, TSH recommendations Reiterate ways to increase activity level
BNP if diagnosis is in doubt Importance of treatment adherence Plan and use a medication system that promotes routine
ECG and behavioral strategies to promote adherence
Chest X-ray
Plan for refills
Risk Populations Echocardiogram (Level of Evidence = C)
repeat after 3 months of medical therapy

Symptoms
to assess need for device therapy (evidence level=
B)
Follow-up Visit Goals (in addition to H&P) Level of evidence = B

Conditions: Frequent: Assess volume status: • Functional Capacity and activity level
Hypertension Dyspnea at rest or with exertion Inquire about orthopnea and PND, edema, abdominal Assess history of arrhythmia, syncope, Functional Capacity and activity
Diabetes Reduced exercise capacity • Changeslevelin body weight
girth
Coronary artery disease
(post MI / CABG / intervention)
Orthopnea
Paroxysmal nocturnal dyspnea Daily weights, Blood pressure/HR/Tem • Patient presyncope
understanding of and compliance
or palpitation Changes in Body Weight
Compliance and response to interventions Patient Understanding of and
(PND) or nocturnal cough Orthostatic BP signs with dietary
compliance
sodium restriction
Peripheral vascular disease Edema (persistent) Directed physical exam •
Cerebrovascular disease Ascites or scrotal edema Modifiable Factors Leading to Hospital Readmissions for HF Patient understanding
The presence of and
of exacerbating compliancewith dietary sodium restriction
factors
• Inadequate patient and family or caregiver education and counseling
Valvular heart disease Heart Failure
• Poor communication andClinic for
coordination Chronic
of care among health Disease
care providers with medical regimen
for HF, i.e, worsening ischemic heart disease, Patient
Cardiomyopathy in a first degree relative understanding and compliance
Occasional and less specific:
Management
• Inadequate discharge planning
Exposure to cardiac toxins
Sleep-disordered breathing Early satiety, nausea/vomiting,
• Failure to organize adequate follow-up care
Rationale:
• Clinician failure to emphasize non-pharmacologic aspects of HF care, such as dietary,
Medication Titration
hypertension, or new/worse valve disease
regimen
with medical
abdominal discomfort
activity, and symptom monitoring recommendations Titration of Heart Failure Medications requires a concerted balancing of neurohumoral inhi
Enhanced risk of Heart Failure: Wheezing or cough • Failure to address the multiple and complex medical, behavioral, psychosocial,
Sustained arrhythmias; AF/flutter Unexplained fatigue environmental, and financial issues that complicate care, such as older age, presence of
while minimizing side effects, optimizing cardiac function and functional capacity and pres
Complex ventricular arrhythmias Withdrawal from customary multiple comorbidities, lack of social support or social isolation, failure of existing social renal function. Details regarding these principles are found in the 2006 Heart Failure Guide
activities support systems, http://www.heartfailureguideline.org/
ECG with LVH, LBBB or pathologic Q waves Confusion/ delirium • functional or cognitive impairments, poverty, presence of anxiety or depression
Cardiomegaly on CXR • Failure of clinicians to use evidence-based practice and follow published guidelines in the
prescription of pharmacologic and non-pharmacologic therapy
HFSA Heart Failure Practice Guideline J Card Failure

When to Refer to Heart Failure Clinic Device Therapy Indications (Level of evidence)
“Patients recently hospitalized for HF and other patients at high risk should be considered for
referral to a comprehensive HF disease management program that delivers individualized
Prophylactic ICD Placement: Biventricular Resynchronization Pacing:
Signs care.

}
High-risk patients include those with:
Cardiac filling pressures/ fluid overload Cardiac Enlargement: • Persistent LVEF < 35%, candidates for ICD or CRT
 Jugular venous pressure/ Hepatojugular reflux Apical LV impulse • Renal insufficiency
•NYHA II-III symptoms and LVEF < 35% (A) •NYHA III and ambulatory IV
displaced or sustained • Diabetes •At time of Biventricular Pacer placement (B) •NSR
Edema Murmurs suggestive of valvular • Low output state •QRS > 120 msec combined
•Survivors of VT/VF arrest without acute MI (A)
S3 gallop dysfunction • COPD •LVEF < 35%
Pulmonary rales • NYHA class III or IV symptoms •Survivors of VT/VF arrest > 48 hrs after MI, •LVEDD > 55 mm Level A
Ascites/hepatomegaly • Frequent hospitalization for any cause without concomitant ischemic event (A)
Peripheral perfusion/temperature • Multiple active co-morbidities
• History of depression, cognitive impairment, or persistent nonadherence to therapeutic
regimens (Strength of Evidence A)